Thursday, September 27, 2012

Last night I was traveling back from California to Ohio. As we landed in Denver, there was severe
weather in the area--mostly rain and lightning--but also some minor hail.

FAA regulations require that, with any
hail, every plane has to be inspected. I heard some of the ground crew bemoaning
the fact that they had to do this, that it was a waste of time, as we loaded
onto our connecting flight.

After the 30 minute inspection, the
pilot explained to us that they found some minor damage on the plane from
the hail and, therefore, we would have to get on another plane. Most likely, this damage would have
never amounted to anything.

Deplaning at 11:30 at night for people
headed east who were tired and grumpy was not a popular procedure. But it was the right thing to do. They were forced to put safety first. It wasn't what any of us wanted last
night--but in the light of day, I am much happier being alive and back
with my family--even if three hours later than anticipated.

It made me think--how often do
we in health care push forward, ignore possible safety/quality issues, out
of convenience or concern of causing someone temporary discomfort?

Wednesday, September 26, 2012

If hospitals ever hope to create a culture of continuous improvement, the people in charge need to learn how to help people learn from mistakes rather than blaming them when mistakes are made. Again and again, we hear stories that indicate a failure to realize this fundamental leadership lesson.

Witch hanging: The result of hysterical blame for ill fortunes

One case occurred last year, an error regarding a kidney transplant at UPMC, where a surgeon was demoted and a nurse was suspended for what was later diagnosed as a series of systemic problems in the organization. Another had a more tragic turn, when a Seattle nurse committed suicide months after being disciplined for administering a fatal dose to an infant, again in an environment with underlying systemic problems.

I quote myself from the blog post describing that last story:

My regular readers know that my former hospital faced a similar issue following a wrong-side surgery.
Would we punish the surgeon and others involved in the case? We
decided not to, not because they had suffered enough themselves from the
error, but because we felt that a "just culture" approach to the issue
would suggest that further punishment would not be helpful to our
overall goal of encouraging reports of errors and near misses. The head
of our faculty practice put it well:

If
our goal is to reduce the likelihood of this kind of error in the
future, the probability of doing that is much greater if these staff
members are not punished than if they are.

Punishment of
those involved in this case also would have diverted attention from the
failures of senior management in doing its job. As Tom Botts from Royal
Dutch Shell commented about deaths on one of his company's oil rigs:

It
was a defining moment for us when we, as senior leaders, were finally
able to identify our own decisions and our own part in the system
(however well intended) that contributed to the fatalities. That gave
license to others deeper in the organisation to go through the same
reflection and find their own part in the system, even though they
weren’t directly involved in the incident.

It also would have diminished the likelihood of widespread interdisciplinary participation
in redesigning the work flow in our ORs. By making clear that the
error was, in great measure, a result of systemic problems, all felt a
responsibility to be engaged in helping to design the solution.

A nurse who accidentally disposed of a living donor's kidney during a
transplant said she didn't realize it was in chilled, protective slush
that she removed from an operating room....[The hospital] said poor oversight and communication and insufficient policies were
factors in the kidney's disposal, which prompted the voluntary,
temporary suspension of the hospital's living-donor kidney transplant
program and led to reviews by health officials and a consulting surgeon
hired by the hospital.

The medical center suspended two nurses after the incident; one was
later fired, and the other resigned, the hospital said. A surgeon was
stripped of his title as director of some surgical services, and a
surgical services administrator put on paid leave has resumed work.

Witch cucking justice: If you survive the dunking you must be a witch

As in the UPMC and Seattle cases, is it possible for anyone working in this hospital to read these three paragraphs and not say, "There but for the grace of God go I"? Think about how the leadership approach that was employed will drive reporting of errors and near misses underground.

The hospital's actions reflect a failure of the leadership to recognize its role in the problems. Contrast that with real leaders, like Tom Botts mentioned above, and Paul Wiles, former CEO of the Novant Health system, discussing preventable infants' deaths in one his hospitals:

My
objective today is to confess. I am accountable for those
unnecessary deaths in the NICU. It is my responsibility to establish a
culture of safety. I had inadvertently relinquished those duties [by
focusing instead on the traditional set of executive duties (financial,
planning, and such)].

If you cannot
see the face of your own relative in a patient, or if you can not see
the face of your own son or daughter in the face of a distraught nurse
or doctor who has made an error, I suggest that your executive talents
would be better placed in other industries.

Marty Makary recently wrote about the persistent level of errors that occur in hospitals, decrying the lack of progress in quality and safety improvement. When you read stories like this one from Ohio, you have no doubt of one major contributing factor, leaders who don't understand what Wiles has stated so eloquently.

My Facebook friend Carrie posted this photo of a truck pretending to be a sardine can as it went through a Storrow Drive underpass in Boston. People who added comments were very quick to blame the driver. It is very easy to do so, as s/he probably didn't notice the sign on the bridge indicating the clearance, but there is a bigger problem here.

I have often told the story of how Bill Geary solved this problem when he was MDC Commissioner in the 1980s. He installed rubber signs
and cowbells (yes cowbells, to make noise) at every entrance to Storrow
and Memorial Drive. The signs were set at a height just slightly lower than the
underpasses. The idea was that your truck would hit a sign and ring the
bell and you would not proceed along the drive and get stuck.

Before Bill invented this low-tech solution, there was one accident
per week on Storrow or Memorial drive. Afterward, they were virtually
eliminated.

Overheight warnings are nothing new, but as you say, they need to be
put up (first) and then maintained in order to be effective.

Signs are fine, but signage at the turn from the Mass Pike Allston
offramp to Storrow Drive is a bad example of our Massachusetts tendency
to assume that everyone who drives on our roads already knows (a) where
they are, (b) where they are going, and (c) how to (or in this case how
not to) get there.

Your comment on that scene illustrates a principle unfortunately common
to governing bodies of organizations (including hospitals) - a problem
is fixed, but the solution, over time, is not maintained, often due to
changes in staff, apathy, etc. Then the problem inevitably resurfaces
and, lo and behold! One must have another whole series of meetings,
discussions, etc. to solve it all over again - because everyone has
forgotten the previous solution, or downsizing has eliminated the
institutional memory. Now THAT also wastes time and resources.

See the next blog post (above) about another case of misplaced blame in the presence of systemic problems.

September
27, 2012: Pioneering ACOs: What Do We Know So Far?2:00
- 3:00 PM Eastern Time

Featuring:

Elliott
Fisher, MD, MPH, Director, Center for
Population Health, Dartmouth Institute for Health Policy and Clinical
PracticePalmer
“Pal” Evans, MD, former Senior Vice
President & Chief Medical Officer, Tucson Medical Center (TMC)John
Friend, Vice President Business
Development & Associate General Counsel, TMC Healthcare;
Executive Director, Arizona Connected Care, LLCOne
of the best-kept secrets about US health care this election season is
the degree to which change and transformation are coming, no matter
what happens in November. You won’t hear “global
payment” or Medicare Shared Savings Program mentioned as
often as “individual mandate” in the current
political debate, but ask anyone leading a health care organization
today which issue keeps them up at night, and it’s definitely
payment reform. In general terms, the entire system is shifting from
paying for volume – lots of procedures – to paying
for value, or how well patients are cared for over time and across the
continuum. Accountable care organizations (ACOs) are one critical new
reflection of this migration, and they’re being encouraged by
public and private payers alike. What do we know about the more than
200 ACOs that have formed in the US thus far? It’s still
early in the process, but some smart people are keeping a close eye on
ACOs, and we’re going to be talking with a few of them on the
September 27th WIHI.As
Director of Population Health and Policy at the Dartmouth Institute for
Health Policy and Clinical Practice, Dr. Elliott Fisher is leading a
major study of the factors enabling ACOs to get up and running and to
successfully implement new forms of care delivery. WIHI
host Madge Kaplan welcomes Dr. Fisher to the show to share what he and
his team of evaluators have learned thus far. He’ll be joined
by leaders from Tucson Medical Center (TMC), one of the
nation’s earliest adopters of the ACO concept. Dr. Palmer
“Pal” Evans and John Friend from Arizona Connected
Care both say that one of the biggest hurdles for newly forming ACOs is
to let go of the notion that hospitals can and should run the show.
That’s not where the future is headed, both say, and
they’re learning this in spades in Arizona. They’re
also learning how to build will and buy-in from mostly independent
physicians, a situation that’s typical of most US hospitals.There
are plenty of uncertainties ahead, but Elliott Fisher, Pal Evans, and
John Friend agree that ACOs or something similar are likely to be a
feature of reform for the forseeable future. They look forward to
sharing their perspectives and answering your questions on the
September 27th WIHI. For some background on Tucson Medical
Center’s entrance into the ACO experiment, please take a look
at these Commonwealth
Fund case studies published
earlier this year.

Tuesday, September 25, 2012

A friend works as an analyst at a major investment house in New York City, and wrote the following after I sent the link below about the opening of The Waiting Room in that town:Thanks. Reminds
me that I have to get re-approved to open your blog at work. I had it okayed
when I first started here. Since it is a blog I had to get permission,
and it was okay, but then they tightened the rules on what we can access and I
got knocked off again.

I responded:

Wow. Think of that. You are expected to be knowledgeable about things that could affect securities valuations, and the firm is closing off the major
source of information to the world--not my blog, but all of them.

The reply:We can't access New York Times articles if the paper calls them
"blogs" either. I do understand that they are trying to protect us and the
system and not have us frittering our time away.

Nonsense. This is just a Neanderthalic view of the world. First, think of what it says about the lack of trust the firm has for its professional staff. Second, it is an ineffectual measure, in that people can just bypass the company's server and use their iPhones for the same purpose.

I previously discussed hospitals and other firms that blocked social media on their servers. This is just plain dumb in the new information age.

---

The sequel! Just received from my friend:

Yeah, I sold out and upgraded to iPhone 4. So I got to read your blog
post after all. Well written. I am in the process now of gathering the
approval emails to attach to the Web Site Blocking Exemption Request.
Need one from my boss's boss, which he sent quite promptly with a nice
GOOD LUCK on it. Now I have to get one back from compliance, and as I
don't know the guy from Adam nor he, me, goodness knows how long this is
going to take. Plus I am spending half my morning on this, plus the
form said it would take 3 days to approve once I submit. And do you know
what the crowning glory is? Even if I get approval again I won't be
able to open any videos!

A note from Peter Nicks and others who produced The Waiting Room, a compelling documentary about patients and staff in Oakland's Highland Hospital. Here's the trailer.

The wait is over.

The Waiting Room opens this Wednesday in NYC and on Friday in L.A.! New York Magazine has named the film a critics pick and described it as "the
kind of observational doc that manages to say a lot by saying very
little— avoiding political grandstanding and instead coolly observing
the characters." And over in L.A.The Hollywood Reporter has
named it an Oscar possibility in their initial assessment of the Oscars
race. Wow! As far as we're concerned that's a huge statement about our
little film and inspires us to work even harder to get the stories of
the beautiful people in the waiting room heard.

We hope you can make it to one of these screenings, but fear not if
you hang your hat in another city. We will be announcing more dates over
the next couple of months in the Bay Area, Boston, DC, Houston,
Seattle, and Minneapolis just to name a few.

Monday, September 24, 2012

I was honored and pleased to be invited to make several presentations today to the governing bodies of the Gundersen Lutheran Health System in La Crosse, Wisconsin. This is an exemplary health system, with a wonderful focus on quality and safety and process improvement, but also with an expanded focus on issues of community concern, like environmental stability.

It is to illustrate this latter front that I am breaking protocol and giving top billing not to the CEO, but to Becky Hamit, his administrative assistant. You see her here sporting a bag made from the recycled material of the cloth that is used to wrap surgical instruments in the operating rooms. Ordinarily, this material is disposed of into landfills, and it is a high quality fabric that does not break down easily. At Gundersen Lutheran, the staff has gotten used to looking for all kinds of ideas to reduce energy use and improve the institution's environmental footprint. They have cooperated with a group of senior citizen volunteers, working through the RSVP organization, to take the fabric and sew it into these handy bags. Some are used to provide clinical information packets to patients, and some are used in other ways. A small example, yes, but illustrative of Gundersen Lutheran's focus on constant improvement.

Ok, now back to Jeff Thompson, CEO of the system, seen here presenting to his Board of Governors and Board of Trustees. As you see from the photo above, Jeff doesn't pull punches with his board about the status of quality and safety issues and other strategic matters facing the board.

My job, after Jeff's update, was to present some thoughts about likely future trends in the industry and what attributes will be needed by high performing organizations. The board members then broke into working groups to discuss risk assessment and mitigation in light of these thoughts. I was not surprised, given this health system's leadership position in the country, to hear extremely thoughtful observations from the board members.

A highlight of the day was a presentation on servant leadership by Dave Skogen, founder and former CEO of Festival Foods. Dave quoted with displeasure Henry Ford: "All I want is their hands and feet. I don't want them telling me how to run the company." Dave stressed the importance of leadership in making feel people appreciated and engaging them in process improvement in an organization. He reminded the group: "The customers want us to serve as their agent for quality, price, and service." But, he said, "You don't manage people. You lead people. Management is what we do. Leadership is who we are. What is it about me that others would change if they could?"

Dave suggests that the first question that should occur in an employee's performance review should be, "How am I doing as your boss?" Only if the leader is serving the staff member well is he or she doing the job right. A wonderful thought from a great leader and coach.

Sunday, September 23, 2012

When there is a plane crash in the U.S., even a minor one, it makes
headlines. There is a thorough federal investigation, and the tragedy
often yields important lessons for the aviation industry. Pilots and
airlines thus learn how to do their jobs more safely.

The world of American medicine is far
deadlier: Medical mistakes kill enough people each week to fill four
jumbo jets. But these mistakes go largely unnoticed by the world at
large, and the medical community rarely learns from them. The same
preventable mistakes are made over and over again, and patients are left
in the dark about which hospitals have significantly better (or worse)
safety records than their peers.

The article is drawn from Marty's recently published book Unaccountable. This trailer will give you a sense of the themes. He notes:

It does not have to be this way. A new generation of doctors and
patients is trying to achieve greater transparency in the health-care
system, and new technology makes it more achievable than ever before.

I hope so, but I don't know. For several years, I have joined Marty, Peter Pronovost, Brent James, David Mayer, Lucian Leape, Jim Conway and others in advocating for changes in medical education, in clinical process improvement, in transparency of clinical outcomes. Those changes are all necessary conditions for a transformation of this industry, not only in the US but in all developed countries.

Unlike these people, I come to this field with a background in other industries, much more than in health care. I have seen and participated in the transformation of other sectors, where the hope was that changes in technology would render previous industry patterns unsuitable. Whether with gentle or forceful steering from the government, it was hoped that the disruption in those industries would result in more customer choices, greater value for each dollar (or pound or peso) spent by consumers, and an overall improvement of efficiency for society. The results in those other fields have been mixed, as is perhaps inevitable when any major sector with extensive vested interests is perturbed. But we can often see some change in the hoped-for direction.

But I have yet to encounter a field that is as recalcitrant to change as health care. While filled with people of the best intentions, intelligence, and extensive training, it is also characterized by self-satisfaction, denial of the underlying problems, and arrogance. Thus far, too, the patient advocates who have tried to cause improvement have not been unified or effective in purpose and plan. Thus, there does not yet appear to be a solid, sustained constituency for the result Marty predicts.

Sometimes, I remind myself to be patient. It is hard to change the medical system quickly. But, more often, I find myself agreeing with the words of Captain Sullenberger:

"I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country. We have islands of excellence in a sea of
systemic failures. We need to teach all practitioners the science of
safety."

Thursday, September 20, 2012

O'Reilly Media has a new conference, Strata Rx, that will be of interest to people who want to bring data science to the healthcare world.

The folks at O'Reilly note:

Big data
holds great promise for the advancement of personalized and predictive
medicine. Used wisely, it can lead to significant cost savings, and even
point to entirely new products and markets. If the conference tagline,
"Leverage the Power of Big Data in Healthcare," gets you excited,
you'll want to join them in San Francisco on October 16-17.

The company has offered a 25% discount to readers of this blog. To claim it, use my
name as a discount code (PAUL) when reserving your seat. Early
registration expires today, September 20, and the price goes up
thereafter. Click here.

I want to invite you to our latest webinar, The Business Case for Lean, with Michael Ballé, taking place at 2:00 p.m. Eastern on October 10, 2012. This is a one hour, free webinar.

"Executives have been asking about the ROI of Lean programs forever.
Lean practitioners answer that it's the wrong kind of question. They are
absolutely right, but we must get better at showing the business
benefits of Lean. That's where I can help." - Michael Ballé.

Parkland Health & Hospital System has reached a settlement agreement
with the Department of State Health Services (DSHS) that resolves and
discharges all potential litigation and enforcement actions for
compliance issues prior to May 31, 2012. Under the agreement with DSHS, Parkland will be assessed $1 million for
violations that occurred prior to June 1, 2012. $750,000 will be payable
within 30 days of the execution of the agreement. $250,000 will be held
in abeyance subject to Parkland’s compliance with the terms of the
agreement.

I understand the need for a closely supervised quality and safety improvement program, but I cannot understand the purpose of a fine, especially when the institution being fined is a non-profit hospital.Why would you take resources away from a hospital when what is needed is for it to invest in an extensive and intensive quality and safety program?

I could even see requiring Parkland to spend this amount on quality and safety programs, but I don't see the point of hurting them financially.

Tuesday, September 18, 2012

It is a sign of the times that one of the most able, experienced, and thoughtful of our state's public administrators has had to take the fall for a series of events that would have been virtually impossible for him to prevent. John Auerbach has been serving as Commissioner of Public Health in Massachusetts for six years. Previously he served as head of the City of Boston Public Health Commission. He has been a calm voice of reason and has received virtually unanimous praise for his dedication and professionalism.

For those of you from out of state, the scandal that erupted related to a scientist at the state's crime laboratory, who had falsified evidentiary reports for many years. This has likely led to overly harsh judgments and criminal sentencing for a number of alleged criminals. The state will now have to go through thousands of case records and work with prosecutors and defense counselors to sort out the mess.

In today's political world, there seems to be a need to assign blame when something like this happens. Whether it might just have been a rogue scientist, or whether there may have been inadequate procedures in the laboratory, or both, is something worthy of review and correction, of course. But the idea that the Commissioner, sitting astride a huge organization of departments and divisions, should be held accountable for this is ridiculous.

Here's the current organization chart for the state DPH. Good luck even finding the division in which this scientist used to work.

John, being the ultimate gentleman and stand-up guy, issued this statement:

It is with deep regret and with a sense of responsibility to uphold
the high ideals Governor Patrick demands that I announce today my
resignation as Commissioner of the Department of Public Health.

It is clear that there was insufficient quality monitoring,
reporting and investigating on the part of supervisors and managers
surrounding the former Department of Public Health drug lab in Jamaica
Plain -- and ultimately, as Commissioner, the buck stops with me.

But the "high ideals" he cites of the Governor apparently do not include the concept that this could have happened in any administration (and indeed apparently started well before John's tenure). Those ideals apparently do not include the concept that someone who has been an exemplary public servant deserves a chance (if he wanted) to try to remedy the underlying problem of the agency. Those ideals apparently do not include any self-blame for the people still higher in the administration, who filed the extremely tight budgets for this agency for several years that may also have contributed to an inability to conduct proper oversight.

No, we seem need to find someone to punish . . . and quickly, to get through the news cycle and put this story behind the administration. The Governor said:

Today, I accepted Commissioner John Auerbach’s resignation. The
failures at the Department of Public Health drug lab are serious and the
actions and inactions of lab management compounded the problem. The
Commissioner recognizes that, as the head of DPH, he shares
accountability for the breakdown in oversight.

Boston Mayor Thomas M. Menino said, “For all the wonderful things he did over the
years, his career should not be blemished by this one incident.”

Let's be clear, Mr. Mayor. This is not a blemish on John's career, and to call it so misconstrues the nature of what has happened here. They needed a fall guy, and he was gracious enough to accept the role without complaint. We citizens owe him a debt of gratitude for years of dedicated public service. Knowing John, I am sure that he will continue to make contributions to the public good wherever he goes and whatever he does.

Meanwhile, though, the Massachusetts political system goes on and eats its young.

Professor Joseph Restuccia runs a terrific course at the Boston University Graduate School of Management entitled "Health Services Delivery: Strategies, Solutions, and Execution." He has been kind to invite me each year to meet with the students and tell how we were able to transform the culture of my former hospital to instill a great emphasis on the safety and quality of patient care, based in large measure on front-line driven process improvement.

I attended last night again and, per habit, told students who gave particularly perspicacious answers to my questions that they might find themselves featured on this blog. So here they are. I include their names so potential employers will know whom to contact when they are looking for recruits!

Monday, September 17, 2012

The first known longitudinal patient safety curriculum that I know of was instituted at the University of Illinois College of Medicine. This was rigorous and thoughtful approach to patient safety, integrated into the undergraduate medical education program. A capstone was a four-week elective that, as David Mayer notes, became increasingly popular as time passed.

Dave recently published two blog posts summarizing this course, here and here. Here's the part I like best:

Students were asked to address 1-3 specific research questions around
each patient safety topic, and to share 2-3 relevant articles from a
literature search that addressed the questions posed. Responses to each
question (no less than 400 words) were then posted on the course
blackboard site so others could then read and respond to their peers’
conclusions as appropriate. Answers to the questions were required to
demonstrate critical thinking and scholarly investigation, and to be
taken from peer-reviewed literature and referenced appropriately. The
interactive, adult-learning format allowed for discourse via the
blackboard around the posted answers. The course provided a forum for
each student to gain substantial knowledge in patient safety, as well as
prepare students for the responsibilities of residency.

These were no easy questions. Look at these, for example:

What are the key risk management concepts non-medical industries use to manage their high-risk operations?

What is a safety culture and how can it help enable creating reliable and patient centered care?

What can we learn from HRO research that can help inform patient safety practices in healthcare?

The course also contained several opportunities for personal reflection, again shared with other classmates. Adding this humanistic tilt to the course presents a great opportunity to break down the interpersonal barriers so often found in medical school and later in the practice of medicine. Here is the summary:

Individual student reflection were assigned for Day 5 of each week,
and designed for students to reflect on the week’s discovery and
learning. Reflections were due on Saturday, and students were instructed
to post comments and reactions to one another’s posts. The reflections
addressed the following questions:

How would you apply what you have learned this week to your professional life?

What are the concepts that made you think differently than before and why?

I was so pleased to receive an informative note from Maria Vertkin, founder and executive director of Found in Translation. This organization has a terrific dual purpose:
"To help homeless and low-income multilingual women to achieve economic security through the use of their language skills; and to reduce ethnic, racial, and linguistic disparities in health care by unleashing bilingual talent into the workforce". The website notes:

Our 12-week Medical Interpreter Certificate course is
offered at no cost to income-eligible women and includes common-sense
supports such as on-site childcare and assistance with transportation.
Upon successful completion of the course, graduates are qualified to be
hired as medical interpreters at hospitals, clinics, and other medical
settings.

As a budding non-profit, Found in Translation can use your help in funding. If you are in the area, you can join in their fall fundraiser on November 16, 2012 from 6:00 PM - 9:00 PM at the Microsoft NERD Center, Cambridge. The event will "celebrate our inaugural year, our graduates' accomplishments, and the diversity of our community!" The celebration will include:

This little diamondback terrapin entered a new world as the New Year began. Let's wish him/her success in a rough environment and remind him/her that sticking your neck out is often--but not always--a good way to make progress.

Friday, September 14, 2012

One of the mysteries of electoral politics is why President Obama doesn't take more credit for those aspects of the Affordable Care Act that are popular, that represent a reduction in anxiety for a portion of the public. It's as if he lets the other guys define the issue in the most negative way.

I recently wrote about one, the guarantee of insurance coverage when someone has pre-exisiting conditions. But an equally attractive feature of the law is the provision that allows young adults to stay on their parents' insurance policy until age 26. For years, many people would graduate college or otherwise enter the work force without health insurance coverage. While these people are, on average, healthier than the general population, the average hides a lot of variation. Plus, this is the time of life when getting used to preventative care is a good habit.

The new law has made a difference. The Commonwealth Fund recently reported on data from the Census Bureau:

Young adults made strong gains in coverage, continuing a trend that
began in 2010 with the passage of the Affordable Care Act. The
percentage of uninsured young adults ages 19 to 25 without health
insurance declined by 2.2 percentage points in 2011, to 27.7 percent,
down from 29.8 percent in 2010 and 31.4 percent in 2009.
This nearly 4 percentage point decline in the share of young adults who
lack health insurance over the past two years reverses the growth in the
uninsured in this age group over the past decade, and is likely
attributable to the Affordable Care Act; young adults under age 26 may now stay on or join their parents' health plans. About 1 million more young adults had insurance coverage in 2011 compared with 2009, prior to the passage of the law.

Wednesday, September 12, 2012

Thanks for the lead from @tgranz (Tracy Granzyk) via TechCrunch Disrupt SF 2012. There are tons of college students and recent graduates inventing new health care gizmos here in the Boston area. Here's a summary of one of them, a new approach to monitoring a person to detect sleep apnea. They made the prototypes using a 3-dimensional printing machine, finding that they could not get the quality or price they wanted from regular production houses.

One
of the most important events of the year for IHI and for the health
care
improvement community is the National Forum. The theme for this
year’s
conference (December 9-12 in Orlando, Florida) is Defining
Moments.
It’s meant to suggest the critical challenges and
opportunities before health care right now — for providers,
payers, and
patients — that will shape the future of health care quality.
In other words,
“seize the moment” and great things can happen
— but only if we act, and act
now.

For
the 24th year in a row, IHI wants to help with your challenges.
That’s why
we’ve secured a big space, and cleared our calendars, in
order to provide you
with as many keynotes, Learning Labs, Minicourses, workshops, Forum
Excursions,
virtual site visits, storyboards, symposiums, and exhibitors that we
can pack
into a few days … knowing that you need the latest knowledge
and the energy of
others who are passionate about patient care to take the next steps.
Who might
you
meet? What might you learn?

WIHI
host Madge Kaplan is gathering some talented people together to walk
you
through the 24th Annual National Forum experience and to give you an
idea of
who’s speaking, who’s attending, and all the
networking possibilities in store.
IHI’s Karen Baldoza will provide a concise overview of the
conference; National
Forum Co-Chair Gilbert Salinas will share his thoughts about the
patient’s
perspective; Laura Adams, Len Berry, and Kathy Luther all have sessions
they’d
like to tell you about but, even more, to explain why they attend the
IHI
National Forum every year. This year’s gathering feels
especially timely (and
defining) to them, too.

Finally,
we are eager to answer your questions and to explain how you can get
the most
out of IHI’s 24th Annual National Forum on Quality
Improvement in Health Care.
No question too small or insignificant. Please join us for this special
National Forum preview on the September 13 edition of WIHI.

Tuesday, September 11, 2012

I am just going to copy this article because it so good. It has been picked up by a number of places.

A unique nationwide patient safety project funded by the Agency for
Healthcare Research and Quality (AHRQ) reduced the rate of central
line-associated bloodstream infections (CLABSIs) in intensive care units
by 40 percent, according to the agency's preliminary findings of the
largest national effort to combat CLABSIs to date. The project used the
Comprehensive Unit-based Safety Program (CUSP) to achieve its landmark
results that include preventing more than 2,000 CLABSIs, saving more
than 500 lives and avoiding more than $34 million in health care costs.

The agency and key project partners from the American
Hospital Association (AHA) and Johns Hopkins Medicine discussed these
dramatic findings at the AHRQ annual conference today in Bethesda, Md.,
and introduced the CUSP toolkit that helped hospitals accomplish this
marked reduction.

“CUSP shows us that with the right tools and resources,
safety problems like these deadly infections can be prevented,” said
AHRQ Director Carolyn M. Clancy, M.D. “This project gives us a framework
for taking research to scale in practical ways that help front-line
clinicians provide the safest care possible for their patients.”

CLABSIs are one type of healthcare-associated infection
(HAI). HAIs are infections that affect patients while they are
receiving treatment for another condition in a health care setting. HAIs
are a common complication of hospital care, affecting one in 20
patients in hospitals at any point in time.

The national project involved hospital teams at more
than 1,100 adult intensive care units (ICUs) in 44 states over a 4-year
period. Preliminary findings indicate that hospitals participating in
this project reduced the rate of CLABSIs nationally from 1.903
infections per 1,000 central line days to 1.137 infections per 1,000
line days, an overall reduction of 40 percent.

The CUSP is a customizable program that helps hospital
units address the foundation of how clinical teams care for patients. It
combines clinical best practices with an understanding of the science
of safety, improved safety culture, and an increased focus on teamwork.
Based on the experiences gained in this successful project, the CUSP
toolkit helps doctors, nurses, and other members of the clinical team
understand how to identify safety problems and gives them the tools to
tackle these problems that threaten the safety of their patients. It
includes teaching tools and resources to support implementation at the
unit level.

The first broad-scale application of CUSP was in Michigan, under the
leadership of the Michigan Health & Hospital Association, where it
was used to significantly reduce CLABSIs in that state. Following that
success, CUSP was expanded to 10 states and then nationally through an
AHRQ contract to the Health Research & Educational Trust, the
research arm of the AHA.

“This partnership between the federal government and
hospitals provides clear evidence that we can protect patients from
these deadly infections,” said AHA President and CEO Richard J.
Umbdenstock. “Hospitals remain committed to curtailing CLABSIs and
enhancing safety in all clinical settings. Tools such as CUSP go a long
way toward accomplishing that goal.”

CUSP was created by a team led by Peter J. Pronovost,
M.D., Ph.D., senior vice president for patient safety and quality at
Johns Hopkins Medicine. “It is gratifying that this method has become
such a powerful engine for improving the quality and safety of care
nationwide,” said Dr. Pronovost. “It is a really simple concept; trust
the wisdom of your front-line clinicians.”

I haven't read the book yet, but this review of Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care by Dr. Marty Makary makes it look like something worth reading.

Here's are some excerpts from the review:

Though concepts such as “accountability” and
“transparency” have been trotted out from time to time, Makary believes
that medicine is still a closed shop. In Unaccountable, he specifically targets hospitals, arguing
that they need to gather, analyze, and publish information vital to
prospective patients. They should keep precise tabs on patients’
surgical outcomes, the rate of hospital-borne infections, and other
measures, and then put the statistics out where the public can see them
(including on the Internet). Doing that would encourage hospitals to
hold themselves to higher standards. They would be forced to
rehabilitate, train, or weed out physicians and other professionals who
need to do better, Makary says, and the practice of medicine would be
greatly improved. By focusing only on best practices, hospitals would also reduce the cost of care.

Meanwhile, hospitals see little gain in presenting statistics about
their performance, Makary says—another impediment to better treatment.
“Their thinking is, ‘What if we have a bad year?’ They’d rather keep the
steady stream of money coming in. They know that people view them as a
beneficent entity, almost a charity.

While many hospitals highlight glitzy new cancer centers, Makary
believes they should emphasize safety at least as assiduously. “Advances
in patient safety will save more lives than chemotherapy this year,” he
says.

For all the brewing hubbub, Makary insists
he’s not so much a single-minded activist as a messenger. “I didn’t
create this movement,” he says. “We’re at a turning point in American
medicine now. There is a new generation of physicians that believes
medicine should be transparent, that is tired of the old b.s., and wants
to change things.” But the old guard isn’t far behind—which gives
Makary even more hope. The Institute of Medicine, a vaunted research
entity that often investigates best practices, and the American Board of
Internal Medicine are starting to take accountability seriously. Even
the doctor-protective American Medical Association has taken notice.
“Doctors are monitoring exactly what they do. They’re researching and
questioning it,” he says. “It’s unprecedented.”

Monday, September 10, 2012

The New York Timesreported on statements made by Mr. Romney on NBC's "Meet the Press:"

I’m not getting rid of all of health care reform. There are a number of things that I like in health care reform
that I’m going to put in place. One is to make sure that those with
pre-existing conditions can get coverage.

I read this and surmised that he said this because he had come to understand a major cause of anxiety among the public in an employer-based health insurance market. Without guaranteed issue provisions, i.e., protection against exclusion for pre-existing conditions, people are at risk for losing health care coverage when they change jobs or if they have not had insurance at all or during an interim period of unemployment.

I was surprised by the comment because in making it, Romney failed to mention something Governor Romney made oh-so-clear to me in a meeting in 2005, as he was advocating for the Massachusetts health reform bill. A concomitant of guaranteed issue is the individual mandate. If people can choose not to buy insurance until the moment they get sick, the broad risk pool of subscribers that is needed to fund insurance benefits will be harmed by a process of adverse selection, raising premiums for all. Absent an individual mandate, a moral hazard is created that guarantees coverage to those who have decided to save money. They then become a burden on society, being bailed out when illness strikes without having paid their actuarial share.

But almost immediately the campaign "clarified" Romney's remarks. As reported by folks at CommonWealth Magazine, the plan he really believes in would prevent those with pre-existing conditions from
being denied insurance if they have had “continuous coverage,” or if
they’ve paid for insurance every month and then enroll in a new plan. It would not include people who have not had insurance at all or for an extended period of unemployment.

Ah, so he is so concerned about not having an individual mandate (something for which he argued strenuously in Massachusetts) that he cleverly proposes to restrict the restriction against denying coverage for pre-existing conditions!

Sunday, September 09, 2012

Ashish Jha, of the Harvard School of Public Health, recently commented on a Massachusetts report about stroke treatment in the state's hospitals. He explained:

The report is about 1,082 men and women in Massachusetts unfortunate
enough to have a stroke but lucky (or vigilant) enough to get to one of
the 69 Massachusetts hospitals designated as Primary Stroke Service
(PSS) in a timely fashion. Indeed, all these patients arrived within 2
hours of onset of symptoms and none had a contradiction to IV-tPA, a
powerful “clot busting” drug that has been known to dramatically improve
outcomes in patients with ischemic stroke, a condition in which a blood
clot is cutting off blood supply to the brain.

So what does this report tell us? That during 2009-2010, patients
who showed up to the ER in time to get this life-altering drug received
in 83.3% of the time. Most of us who study “quality of care” look at
that number and think – well, that’s pretty good. It surely could have
been worse.

Pretty good? Could have been worse? Take a step back for a moment: if
your parent or spouse was having a stroke (horrible clot lodged in
brain, killing brain cells by the minute) – you recognized it right
away, called 911, and got your loved one to a Primary Stroke Service
hospital in a fabulously short period of time, are you happy with a 1 in
5 chance that they won’t get the one life-altering drug we know works?
So what might state and federal policymakers do if they wanted to get
serious about improving these rates? There are lots of potential
solutions, including greater training, more oversight, even robust
pay-for-performance. I have a simpler request:

Stop setting the benchmark at the state average.

Ashish is right on point. In several earlier posts, I have talked about how the use of benchmarks can be inimical to clinical quality improvement, stating a preference instead for absolute targets, like zero or 100%. For some reason, many state and federal agencies persist in comparing hospitals to the norm.

It is not ok to be in the middle of the distribution of the number of
people we are killing.

I have told the story of being at a hospital where the CEO said directly to his
senior management and clinical leaders that his goal was to be “just above
average” when it came to quality and safety metrics. A CEO who has
chosen not to do that has, in essence, said that the loss of hundreds of lives
at his institution is acceptable.

My
objective today is to confess. I am accountable for those
unnecessary deaths in the NICU. It is my responsibility to establish a
culture of safety. I had inadvertently relinquished those duties [by
focusing instead on the traditional set of executive duties (financial,
planning, and such)].

If you cannot
see the face of your own relative in a patient, or if you can not see
the face of your own son or daughter in the face of a distraught nurse
or doctor who has made an error, I suggest that your executive talents
would be better placed in other industries.

Saturday, September 08, 2012

It's not too late to participate in Sunday's Reason to Ride, a biking fundraiser for cancer research in Danvers, MA. Organized by brain cancer survivor Tom DesFosses, this annual event gives participants the option of 10-, 25-, or 50-mile bike rides through beautiful farm land in Massachusetts' north shore (Danvers, Wenham, Ipswich, Essex, Gloucester, and Topsfield).
Registration is $25 per child, $50 per adult, and $150 per family to
benefit cancer care and research at Beth Israel Deaconess Medical Center. The family-friendly event also features a trike-a-thon for kids,
a Fuddruckers cookout, raffles, music, and much more.

Once again, this year’s presenting sponsor is Fuddruckers. Support for
the ride also comes from The Print House, Beverly Cycles, Kelly Fiat,
Jungle, and People’s United Bank.

The ride is on, rain or shine, although the weather promises to be lovely. Registration starts at 8am. The 50-mile ride starts at 8:30; the 25-mile starts 9:30; and the 10-mile starts 10:30. Meet at the Liberty Tree Mall in Danvers.

"Small" diseases, those occurring to a very small percentage of the population, are often ignored by the research funding agencies. But sometimes people overcome this problem by creating their own advocacy organizations to raise funds and sponsor research outside of the normal grant-making process--and also create a community of interest among patients, health care providers, and researchers. Social media makes this more possible than ever.

Such is the case with Adenoid Cystic Carcinoma (ACC), a rare cancer of secretory glands, typically originating in the head and neck region. ACC is diagnosed in only about 1200 cases per year and afflicts about 10,000 people in the US. The disease often afflicts young and middle-aged patients. The median age at
diagnosis for ACC patients is a decade younger than for all cancer
patients.
ACC’s progression is typically gradual and sometimes relentless. The
disease has a tendency to grow along nerves and metastasize to the
lungs.

My friend Marnie Kaufman was 38 years old, with four sons under the age of 10,
when she received her diagnosis of ACC. Frustrated at the
lack of ongoing ACC research, she and her husband, Jeff, formed the Adenoid Cystic Carcinoma Research Foundation in
2005. This has been a well run and thoughtful organization, and they now note the establishment of a new website:

The website serves a pivotal role as a clearinghouse of high quality information for both patients and researchers. For patients,
we have reorganized the navigation to make it simple to find
information related to each stage of disease or a particular treatment. For researchers, we have presented a centralized inventory of research resources. And for the entire ACC community, we have summarized past and ongoing ACC research projects.

Lucien Engelen @lucienengelen reports on the creation of realshare, a new social network for young people with cancer, aged 16-25, who live in the South West part of the UK. A collaborative program with SouthWest NHS and the Youth Cancer Trust, the site offers the following introduction:

You may not get to meet many other young people in your situation where
you are, so realshare gives you a chance to link up with others all
over the South West from Bath to Barnstable, Torquay to Truro. realshare
also provides information about treatments and support, events in the
area, and even includes a Game Zone if you just want to chill out.

Unlike other social networks realshare is closed to members only. You
might find it easier to talk about things with other people in a similar
situation to you. The forums are moderated by local outreach nurses who
treat young people with cancer.

Lucien is Director Radboud REshape & Innovation Center at Radboud University Nijmegen Medical Centre. His favorite topic is the power of social media in helping patients learn, navigate, and collaborate in the context of a health care environment with rising demand, shortages of skilled staff and
restrictive budgets. Check out this article in the Guardian:

We tend not to use the biggest resource in healthcare – the patients
themselves. So I'm trying to figure out possible uses for digital
technologies like Facebook but also real-life social networks to
improve healthcare provision.

Over the past decades we have tended to take healthcare away from the
people themselves. This started with bringing people into hospitals
rather than caring for them in their homes. Healthcare has become
centralised in institutions, rather than in networks as it was in the
old days. But new technology is enabling us to reverse that, while
keeping the same high standards.

Friday, September 07, 2012

Living next to a soccer field has many advantages, but sometimes you also see things that are troubling. Today, as storms approached and lightning and thunder were clearly in close range, the coaches of our boys and girls teams kept practicing with the children.

Referees are taught the 30-30 rule when it comes to lightning, and coaches should obey it, too. It is as simple as this: Go inside if you hear thunder within 30 seconds of a lightning flash. Wait at least 30 minutes after you hear thunder before going back outside.Here are the top ten myths about lightning safety. The most pertinent one, given today's lapse of judgment, is this:Myth: If it's not raining, or if clouds aren't overhead, I'm safe from lightning.Truth: Lightning often strikes more than three miles from the thunderstorm, far outside the rain or even thunderstorm cloud.

Here is a great quiz
about lightning prepared by the National Weather Service. It has only
ten questions, and you are bound to learn something new.

For some time running now, it has been useful for Partners Healthcare System to give the impression that it is under intense competition from for-profit Steward Health Care for patients in the Boston metropolitan area. It suits the corporate image of a near-monopoly provider that faces antitrust concerns to characterize things in such a way. The media in town often repeat this contention.

But, as I have made clear for some time, Steward's main competition is not Partners. It is the community hospitals near the ones it owns in several of the areas surrounding Boston.

Now, we hear it directly. Here's a comment from one of the leaders of a physician group (Hawthorn) that has just been acquired by Steward:

Girard said Steward does not consider itself a Partners competitor.
Noting that Steward hospitals themselves refer many patients to the
Boston organization’s hospitals for some complex care, he said,“We’re
actually a complement to Partners.”

As Rob Weisman's Boston Globe story notes:

Partners -- the state’s largest health care and physicians group and the
owner of Harvard-affiliated Massachusetts General and Brigham and
Women’s hospitals in Boston -- doesn’t run any hospitals along the
state’s South Coast where Hawthorn operates.

But what of the physician group acquisitions themselves? Aren't those an indication of competition from Steward? The inside story is that there has often been contention and disaffection between far-flung doctors' groups and the folks at Partners. There is also no loyalty. The community doctors will go where the money is. As I have noted, Steward needs to show top-line revenue growth as part of its private equity strategy. It faces few constraints on what it is willing to pay physician groups, and so it can offer those doctors more than they get from Partners. For its part, Partners really doesn't care. It will still get the tertiary referrals from these doctors but will not longer need to support them financially. And then it can tearfully say, "You see, there is competition."

Wednesday, September 05, 2012

I am very pleased to announce that Edgar H. Schein, Management Professor Emeritus at MIT, and author of Helping: How to offer, give and receive help has graced my second printing of Goal Play! with a foreword. Ed is one of the acknowledged world experts in industrial organization and management, and he has kindly told me: I think your book is one of the best leadership books I have ever
read. I agree with the lessons but, more important, I love the
presentation around the concrete stories of coaching girl’s soccer.
That brings it all home better.

I am happy to help publicize this year's version of the Costs of Care essay contest. Cash prizes are to be awarded in pursuit of the the goal of expanding the public discourse on
the role of doctors, nurses, and other caregivers in controlling healthcare
costs. Details are here. Here's more information from organizer Neel Shah, including a list of this year's judges:

As
a presidential election looms and the American economy struggles to recover, the
spiraling costs of healthcare have become a contentious political focal point without
an obvious solution. Traditionally, health care providers have been reluctant
to discuss their own role in healthcare spending. However according to Neel
Shah, M.D., Executive Director at Costs of Care, “Ultimately, no amount of
regulating, reorganizing, or otherwise reforming the healthcare system will
successfully contain costs unless healthcare providers are invested in fixing
the problem.”

To
help mobilize healthcare providers to examine their own role in spending, Costs
of Care is launching an essay contest that will collect and widely
disseminate stories from the frontlines of medicine.

$4000
in prizes will be awarded to winning entries, with the help of four judges:

·Pauline Chen, surgeon and New York Times
columnist

·Jeffrey Drazen, Editor-in-chief, New England
Journal of Medicine

·Donna Shalala, former United States Secretary
of Health and Human Services

·Ezekiel Emanuel, ethicist and former White House
healthcare advisor

Preference will be given to
stories that best demonstrate the importance of cost-awareness in medicine.
Examples may include a time a patient tried to find out what a test or
treatment would cost but was unable to do so, a time that caring for a patient
generated an unexpectedly a high medical bill, or a time a patient and care
provider figured out a way to save money while still delivering high-value
care.

All submissions will be due on November
15th, 2012. All qualifying submissions will be
published biweekly at www.costsofcare.org
during the 2013 calendar year, and will be made available to the media.

The
contest is sponsored in part by through the generosity of Blue Cross Blue
Shield of Massachusetts, Harvard Pilgrim Health Plan, Tufts Health Plan, Beth
Israel Deaconess Medical Center, the Wellpoint Foundation, and the ABIM
Foundation.

About Costs of Care

Costs of Care is a nonprofit organization
that gives patients and their caregivers information they need to deflate
medical bills, while expanding the national discourse on the role of care
providers in responsible resource stewardship. Costs of Care was founded by a
resident physician based at Harvard Medical School who noticed that even the
best physicians sometimes overlook something critical—the bill.